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Acute Pancreatitis in Dogs and Cats: Medical Imaging, Biopsy, Treatment and Prognosis Acute Pancreatitis Bij Honden En Katten: M

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Acute Pancreatitis in Dogs and Cats: Medical Imaging, Biopsy, Treatment and Prognosis Acute Pancreatitis Bij Honden En Katten: M Vlaams Diergeneeskundig Tijdschrift, 2010, 79 Theme: acute pancreatitis in dogs and cats 99 Acute pancreatitis in dogs and cats: medical imaging, biopsy, treatment and prognosis Acute pancreatitis bij honden en katten: medische beeldvorming, bioptname, behandeling en prognose 1I. Van den Bossche, 1D. Paepe, 2J. Saunders, 3M. Hesta, 1S. Daminet 1Department of Small Animal Medicine and Clinical Biology 2Department of Medical Imaging of Domestic Animals 3Department of Nutrition, Genetics and Ethology Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, B-9820, Merelbeke, Belgium [email protected] ABSTRACT Diagnosing acute pancreatitis in dogs and cats is difficult. Abdominal ultrasonography provides specific information about the size, shape and homogeneity of the pancreas, but is very dependent on the experience of the operator and the quality of the echography machine. Abdominal radiography is less useful, while computed tomography is less practicable in veterinary patients because of the anesthesia risks, the need for experienced operators, and the high cost. Furthermore, computed tomography has low diagnostic value in cats. Biopsy of pancreatic tissue remains the gold standard. Treatment consists of fluid therapy and nutritional support, combined with pain medication, anti-emetics and antibiotics. The prognosis in dogs and cats is variable and largely depends on the clinical condition of the patient at admission. It is usually guarded, especially in cats. SAMENVATTING Het diagnosticeren van acute pancreatitis bij honden en katten is moeilijk. Abdominale echografie verschaft specifieke informatie over de grootte, vorm en homogeniciteit van de pancreas maar is erg afhankelijk van de ervaring van de uitvoerder en de kwaliteit van het echografietoestel. Radiografieën van het abdomen zijn minder nuttig, terwijl computertomografie minder bruikbaar is bij diergeneeskundige patiënten omwille van het anesthesierisico, de nood aan ervaren uitvoerders en de hoge kostprijs. Bovendien heeft computertomografie een lage diagnostische waarde bij de kat. De biopsie van pancreasweefsel blijft de gouden standaard. De behandeling omvat vloeistoftherapie en nutritionele ondersteuning in combinatie met pijnmedicatie, anti-emetica en antibiotica. De prognose bij de hond en de kat is variabel en afhankelijk van de klinische toestand van de patiënt op het tijdstip dat hij aangeboden wordt, maar ze is meestal gereserveerd, vooral bij katten. INTRODUCTION MEDICAL IMAGING In practice, acute pancreatitis is a common disorder Radiography which can be difficult to diagnose. Because of the nonspecific signs and limitations of the currently avai- Under normal circumstances, the pancreas is not vi- lable laboratory tests, medical imaging plays an im- sible on plain radiographs (Simpson and Lamb, 1995; portant role in diagnosing acute pancreatitis in dogs and Bischoff, 2003). In dogs with acute pancreatitis, in crea- cats. Because delayed therapy can lead to a fatal out- sed opacity and loss of visceral detail can be seen in the come, a rapid recognition of the disease is important. right cranial abdomen (‘ground glass’ appearance) as- This report is the second one in a series of three, which sociated with local peritonitis (Hess et al., 1998; Bi- gives a review of acute pancreatitis in dogs and cats. schoff, 2003; Ruaux, 2003) (Figures 1a and 1b). On This article will discuss the indications, as well as the ventrodorsal projections, the inflamed pancreas can advantages and disadvantages of the various medical cause a displacement of the pyloric antrum to the left, imaging techniques and of pancreatic biopsies. In ad- the descending duodenum to the right and the trans- dition, the treatment options and prognosis will be re- verse colon caudally (Simpson and Lamb, 1995; Hess viewed. et al., 1998; Bischoff, 2003; Ruaux, 2003; Mix and Jo- nes, 2006). In some patients, the proximal duodenum appears dilated and fixed (C-shaped), displaced late- 100 Vlaams Diergeneeskundig Tijdschrift, 2010, 79 Figure 1a. Loss of serosal detail in the right cranial ab- domen (arrow) on a ventrodorsal radioraphic image of a dog with acute pancreatitis. rally and dorsally, with a widening of the pyloroduo- denal angle (Bunch, 2003; Ruaux, 2003; Watson, 2004). A static gas pattern can be noted in the trans- verse colon and the descending duodenum, the wall of which can be thickened (Hess et al., 1998; Bischoff, 2003). Gastric distention suggesting gastric outlet ob- struction is another possible abnormality (Bunch, 2003). Radiographs of the thorax can show pleural ef- fusion (Bischoff, 2003) or pulmonary disease (edema Figure 1b. Lateral radiographic image of the abdomen of or pneumonia) (Hess et al., 1998). the dog seen in figure 1a. Unfortunately, in one study of fatal cases of canine pancreatitis (Hess et al., 1998), these possible abdo- abdomen can be evaluated at the same time. In addi- minal radiographic signs compatible with acute pan- tion, it is becoming more available for general practi- creatitis were seen in only 24% of the patients, whereas tioners (Watson, 2004). It is however important to un- 68% showed ultrasonographic abnormalities sugge- derline that the diagnostic value of US is strongly stive of pancreatitis. Therefore, abdominal radiography operator and machine dependent. Furthermore, the de- has a low sensitivity in diagnosing pancreatitis. In gree of pancreatic inflammation and edema also plays spite of this disadvantage, radiography offers the as- a role (Simpson and Lamb, 1995; Ruaux, 2003; Wat- sessment of other abdominal organs for ruling out dif- son, 2004; Mix and Jones, 2006). In contrast to radio- ferential diagnoses, such as intestinal foreign body. graphy, ultrasonography gives more specific informa- Furthermore, radiography is a widely and easily avai- tion about the size, shape and homogeneity of the lable technique, which remains relatively inexpensive. pancreas (Simpson and Lamb, 1995; Bunch, 2003; Radiography can be used in conjunction with abdomi- Watson, 2004). However, false negative results are nal ultrasound (Watson, 2004; Mix and Jones, 2006). possible (Ruaux, 2003), while not all lesions can be In cats with acute pancreatitis, the same radio - correlated with the clinical status of the patient (Mix graphic changes can be seen as in dogs (Gerhardt et and Jones, 2006). Therefore, it cannot be used as an ex- al., 2001; Ferreri et al., 2003). However, these signs clusion diagnostic procedure. In cats, more work has are often subtle and inconsistent (Hill and Van Winkle, been published to evaluate the sensitivity of several US 1993; Mansfield and Jones, 2001), and the most abnormalities of the pancreas. In contrast, the availa- reported features are reduced abdominal contrast (28- ble information in dogs is limited and further investi- 50%), dilated bowel loops (24-42%) and pleural gation is required. effusion (20-29%) (Gerhardt et al., 2001; Saunders et Most typically, there is a focal area of pain when al., 2002; Ferreri et al., 2003). In cats, hepatomegaly the US probe is placed over the region of the pancreas. can be seen in cases of concurrent hepatic lipidosis Due to edema, pancreatic swelling and peri-pancreatic (Akol et al., 1993). fat necrosis, the inflamed pancreas is more easy to localize than the normal pancreas (Watson, 2004). Abdominal ultrasonography Findings suggestive for acute pancreatitis in dogs include a diffusely enlarged pancreas (more than 2 cm One of the most reliable and increasingly used diag - in diameter) with hypoechoic parenchyma, hyper - nostic tools for pancreatitis in dogs and cats is ultra- echoic surrounding mesentery and generalized or local sound (US) of the abdomen. US has the advantage of peritoneal effusion (Simpson and Lamb, 1995; Hess et being non-invasive, safe and relatively low in cost. In- al., 1998; Ruaux, 2003; Mansfield, 2004; Watson, formation can be obtained immediately and the whole 2004; Mix and Jones, 2006) (Figure 2). Thickening of Vlaams Diergeneeskundig Tijdschrift, 2010, 79 101 Figure 2. Ultrasonographic image: hypoechoic enlarged Figure 3. Ultrasonographic image: hypoechoic enlarged pancreas (big arrow) lined by hyperechoic mesentery pancreas (big arrow) with several, regularly outlined (small arrow) in a dog with acute pancreatitis. hyperechoic spots (small arrow) in a cat with acute pan- creatitis. irregular or hypoechoic pancreas and hyperechoic peripancreatic mesentery were found by Kimmel et al. (2001) in respectively 64% and 43% of the cases involving cats (Figure 3). Beyond this, more subtle and non-pancreatic changes can be diagnostically impor - tant as well. Additional ultrasonographic abnormalities in cats include abdominal effusion (31-45%), distention of the gallbladder and common bile duct (17-24%) (Figure 4), and thrombosis of the pan - creaticoduodenal vein (5%). A hyperechoic, enlarged liver consistent with hepatic lipidosis was seen in 28- 45% of cats with acute pancreatitis (Akol et al., 1993; Figure 4. Ultrasonographic image: dilation of the com- Gerhardt et al., 2001; Kimmel et al., 2001; Saunders et mon bile duct (arrow) in a cat with acute pancreatitis. al., 2002; Ferreri et al.; 2003). Less frequent findings included small hyperechoic kidneys, mesenteric the stomach or duodenal wall and dilated bile ducts lymphadenopathy, intestinal abnormalities and small can be present (Simpson and Lamb, 1995; Bunch, gallbladder with inspissated bile (Saunders et al., 2003; Watson, 2004; Mix and Jones, 2006). In one 2002). study, pancreatitis was
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